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sS A Ni0 4Q U I N <br /> d Environmental Health Department <br /> n , <br /> C 'j N I Y <br /> Corrective Action Statement <br /> RE : June 28 , 2021 , Underground Storage Tank inspection report <br /> For each violation listed below, indicate if the violation has been corrected or will be corrected by a certain date . Also, <br /> describe what was done to correct the violation in the space provided below each violation . Submit this completed <br /> form with the Return to Compliance Certification within 30 days of inspection . If you have any questions , please <br /> contact Paul Nso at (209 ) 616-3049 or pnso@sjgov.org . <br /> Facility name : Mossdale Chevron Submit completed form to <br /> Facility address : 444 W MOSSDALE RD SJC ENVIRONMENTAL HEALTH DEPARTMENT <br /> CERS ID: 10180551 ATTN : PAUL NSO <br /> PR0231692 1868 E HAZELTON AVENUE <br /> STOCKTON , CA 95205 <br /> Violation #107 - Failure to submit and maintain complete and current financial responsibility documents. <br /> 12 This violation was corrected ❑ This violation will be corrected by (date) : <br /> ❑ Supporting documents included <br /> Describe actions taken or will be taken to correct violation : Prr& IL LLOOC?,., Co. Y\Wk 2 r 'L) <br /> T <br /> Violation #118 - Failure to submit the "Overfill Prevention Equipment Inspection Report Form" within 30 days. <br /> 9 This violation was corrected ❑ This violation will be corrected by (date) : <br /> ❑ Supporting documents included r) <br /> Describe actions taken or will be taken to correct violation : 1y\ �3 pF' c. `c^-L- Welzi o oA-v�jc t� <br /> Violation #122 - Failure to implement corrections and submit written response within 30 days of receiving the <br /> report. <br /> 101 This violation was corrected ❑ This violation will be corrected by (date) : <br /> ❑ Supporting documents included <br /> Describe actions taken or will be take to correct violation : Ifs (.( /kTto, /r C `� �� 4-C4 ird <br /> �4�t z v Lu ItA <br /> Page 2 of 3 <br /> Rev. 9/16/2020 <br /> 1868 E . Hazelton Avenue i Stockton , California 95205 1 T 209 468-3420 F 209 464-0138 1 www. sjgov. org/EHD <br />